Each page (front and back) of service documentation notes will contain the person served first and last name. In the case of electronic documents, the person's first and last name must appear on each screen when viewed electronically and on each page when printed. As part of the medical record, the medical assistance identification number and the date of birth must also be identified and associated with the person served first and last name.
The service log will reflect the reason for performing the service or activity, substantiate the necessity, and demonstrate the level of care associated with the service. This will include description of the staff intervention, staff's reinforcement for successful completion, and how the person served responded to services authorized in the person's plan of care.
Question 1: The person served first and last name, as well as a description of the staff intervention and how the person served responded to services, are all required in service documentation.
Service documentation will include the complete date of the service, including the start and end time. For 24-hour services, documentation for every shift of the services provided, the person served responses to services provided, and the staff who provided the service will all be included on the service log. The date format will specify: mm/dd/yyyy (e.g. 01/11/2011) Where services are delivered across two days, the beginning and ending date will be identified. The following date format will be used: mm/dd/yyyy -mm/dd/yyy (e.g. 01/11/2011-01/12/2011). Service documentation will specify the location where the service was provided (e.g. home, community employer, bank, Wal-Mart, etc) and the specific times that formal supports were provided throughout the shift. Any supplies dispensed as part of the service will also be specified.
Question 2: The complete date of service and location of where services were provided are both required in service documentation.
Service documentation will also include the name, dosage, and route of administration of any medication dispensed or administered as part of the service. This would be considered the medication administration record for persons served.
Service logs will include the date, printed and signed first and last name and credentials/title of the staff providing the service. Electronic records will be signed electronically.
Documentation should be completed by the end of the staff's workday, during approved Company paid time, and at an approved service location. Approved service locations are generally the site where service was delivered. When that is not possible, employees may complete their documentation in their car or a nearby approved location. Documentation should not be done at an employees home or at any location not approved, or outside of Company paid time. Late entries require approval by a manager.
Question 3: Service documentation should be completed by the end of the staff's work day, on Company paid time, and only at an approved location.
Concurrent Service Documentation:
It is the intent of Progress Industries to standardize documentation practices across all services. While documentation is not generally completed during service time, IME acknowledges that continuing to interact with the person served during service delivery while briefly documenting the persons served actions and the services provided throughout the session would facilitate accurate documentation (as opposed to a more lengthy solitary documentation session during which the person served is unattended and uninvolved). In this context, initiating real-time documentation can occur in order to help staff focus on the goals for the person served. This real-time documentation would facilitate recording real-time responses from the person served.
Question 4: Service documentation is not generally completed during service time. However, it is acceptable to briefly document persons served actions during service delivery, while continuing to interact with the person served, in order to facilitate accurate documentation.
Concurrent service documentation can not add time to the billable service and is intended to achieve the following benefits:
1. Help PI staff focus on specific goals for the person served by use of a checklist to follow with specific prompts for the goals and activities of each person served.
2. Increase the accuracy of documentation because the staff would be immediately recording responses, as opposed to relying on memory at the end of a shift.
3. Reduce documentation time if the real-time documentation form can be incorporated into or attached to the person served clinical record so the staff does not have to re-enter the same information in the clinical record at the end of the shift.
It is important to note that the remainder of narrative notes will have to be
completed after the billable service time ends as service time cannot be extended to include time for completing extra documentation.
Question 5: Time needed to complete service documentation can not extend the billable service time.
For services using paper documentation methods, these real-time documentation templates will be created by the program manager in conjunction with the supervising coordinator. The company's electronic data system may function as a real-time checklist for this purpose, if feasible. Paper templates will include on each page (front and back) the minimum state requirements for documentation (person served full name, Medicaid identification number, date of birth, printed and signed staff name, title, and full date of service, begin and end times, transition times, specific times that formal supports were provided throughout the shift, and location(s) of service). Completed documentation will include a description of staff interventions and person served responses to Medicaid goals. This will be in sufficient detail to justify the time billed for the service. A simple list of what the staff did or what the person served did is not sufficient.
Documentation of staff training in these matters, with staff signature indicating understanding and agreement will be maintained in staff HR records.
Question 6: Real-time documentation templates need to include all of the same identifying information as other service documentation.
Service documentation should be reviewed by the manager/program manager/QMRP according to their assigned review schedule before submitting a claim for reimbursement. The Coordinator is responsible to ensure the availability, maintenance and retention of service documentation for each person served.
a. Service documentation may be corrected by the staff who provided the service or by a person who has first-hand knowledge of the service.
b. Corrections will not be written over or otherwise obliterate the original entry. A single line may be drawn through the erroneous information (paper records), keeping the original entry legible. In the case of electronic records, the original information must be retained and retrievable.
c. Any correction must indicate the staff making the change and any other person authorizing the change, must be dated (mm/dd/yyyy) and signed (full signature, not initials) by the person making the change and must be clearly connected with the original entry in the record.
d. If a correction made after a claim has been submitted affects the accuracy or validity of the claim, an amended claim must be submitted.
Retention: The manager is responsible for moving the documentation at the end of the month to the central file location, assuring that all the required information is present. At the end of the calendar year, documentation is archived in the storage warehouse after cataloged in the records database. Anyone checking out records from the central file or archival location must sign these records out and back in after review.
Question 7: Service documentation can be corrected by any manager.
Question 8: When making a correction, staff may draw a single line through the erroneous information (paper records), keeping the original entry legible.
Question 9: Any correction must be dated and signed by the person making the change.
Question 10: Service documentation must include the specific times that formal supports were provided throughout the entire shift
Documentation for services provided on an hourly basis need special consideration. Hourly services are provided to individuals to support them in approved goals and/or programming. The only services that should be provided to these individuals are those that have been approved by the team and are listed in their annual plan. If programming or goals need to be changed or updated, staff should contact the program manager.
During service delivery time for hourly services, staff:
● may document only for that person served
● may document, as stated in our policy, using concurrent documentation
● may document during approved DBT time (documentation/break/travel)
● may document at approved locations only
● cannot document on another person served during another's service time (if you are
working with Joe, you cannot complete documentation for Sue).
● must call your supervisor if you need additional time to complete your documentation
● must complete documentation by the end of your work day.
Question 11: What is required when providing hourly services?
Question 12: Staff should notify their supervisor when?